Anxiety Disorders And ObsessiveCompulsive Disorders
Dr. Raafat Al Owesie, M.D.MSc
Consultant Psychiatrist
Head Psychiatry and Psychology
ANXIETY AND FEAR
ARE NORMAL!!
SERVES IMPORTANT
ROLES:
ADAPTATION, INITIATION,
MOTIVATION
ANXIETY PREPARES US TO
TAKE ACTION
AND IS NORMAL IN MODERATE
AMOUNTS
Benefits of anxiety
Yerkes-Dodson law:
Performance
improves as a
function of anxiety up
to a threshold beyond
which there is a fall
off in performance
The Continuum Between
Normal and Abnormal Anxiety
• Anxiety is an expectable part of everyday life
• Pathological anxiety is on the extreme end of
the continuum for
– Trait anxiety: how anxious a person
feels in general (as in generalized
anxiety disorder) and/or
– State anxiety: how anxious a person
feels in response to specific events
(as in phobias)
WHAT ARE ANXIETY
DISORDERS?
• A group of 7 diagnosable disorders
– some shared features
– some distinct
• The most prevalent group of psychiatric
conditions
DIAGNOSING ANXIETY DISORDERS
DSM 5
PANIC DISORDER
AGORAPHOBIA
GENERALIZED ANXIETY DISORDER
SOCIAL PHOBIA
SPECIFIC PHOBIA
SEPERATION ANXIETY
SELECTIVE MUTISM
SHARED CLINICAL FEATURES
• Triggered by innocuous stimuli
• Maladaptive thinking patterns: tend to
catastrophize, misjudge probability
• Prominent physical symptoms: autonomic
arousal
• Typical behavioral responses: escape,
avoidance, help-seeking
WHY ARE ANXIETY DISORDERS IMPORTANT?
THE MOST PREVALENT PSYCHIATRIC DISORDERS IN ADULTS
ANY ANXIETY
DISORDER
MALE
FEMALE
LIFETIME
LIFETIME
19.2%
30.5%
NATIONAL COMORBIDITY STUDY
Kessler et al Arch Gen Psychiatry Jan 1994
ANXIETY DISORDERS CAUSE IMPAIRMENT
Daily life effects
• Physical functioning
• Social functioning
• Pain
• Fatigue
• General health
• Sense of well being
Increased risk of
• Less Income
• Fewer than 16 years
of education
INCREASED RISK OF SUICIDE
• Overall Anxiety Disorders associated with 3
fold risk for suicide attempts
– PTSD: 6 fold risk
– Panic Disorder and GAD: 5.6 fold risk
– Social Phobia: 2.1 fold risk
Kessler et al. Arch Gen Psychiatry. 1999;56:617.
COMORBIDITY
Anxiety Disorders co-occur with many
mental and physical disorders, esp.
• Major Depression
• Bipolar Disorder
• Other Anxiety Disorders
• Substance Use Disorders
Comer, Ronald J., Fundamentals of Abnormal Psychology, Seventh
Edition
Copyright © 2014 by Worth Publishers
ANXIETY DISORDERS ARE ASSOCIATED
WITH BIOLOGICAL CHANGES
•Brain Imaging Abnormalities
•Autonomic Activation
•Neuroendocrine Changes
•Early Bio-behavioral Changes
Amygdala
Lateral Nucleus
• Creates link between conditioned and unconditioned
stimulus
• Exposure to subsequent relevant stimulus, activates
Central Nucleus: (coordinates fear response)
– periaqueductal gray region - freezing or immobility
– lateral hypothalamus - autonomic responses
– paraventricular hypothalamus – neuroendocrine
Shift From Passive Fear to Active Coping in the Brain
LeDoux J and Gorman J Am J Psychiatry 158:1953-1955, December 2001
Generalized Anxiety Disorder (GAD)
• Characterized by excessive “free floating” anxiety
under most circumstances and worry about
practically anything
– Symptoms: feeling restless, keyed up, or on edge;
fatigue; difficulty concentrating; muscle tension,
and/or sleep problems
– Must last at least 6 months
Specific Phobia
• Marked or persistent fear (>6 months) that is
excessive or unreasonable cued by the
presence or anticipation of a specific object or
situation
– Anxiety must be out of proportion to the actual
danger or situation
– It interferes significantly with the persons
routine or function
Specific Phobia
• Epidemiology
– Up to 15% of general population
– Onset early in life
– Female: Male 2:1
• Etiology
– Learning, contextual conditioning
• Treatment
– Behavioural,Systematic desensitization
How Are Specific Phobias Treated?
 Systematic desensitization
 Teach relaxation skills
 Create fear hierarchy
 Pair relaxation with feared objects or situations
 Since relaxation is incompatible with fear,
relaxation response is thought to substitute
for fear response
 Several types:
 In vivo desensitization (live)
 Covert desensitization (imaginal)
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Panic Disorder
PANIC ATTACK
• Sudden escalation and rapid crescendo peak of
4 or more symptoms (physical symptoms
prominent
• Panic can be
– Spontaneous
– situation predisposed
– situation bound
• Can occur with any anxiety disorder and many
other physical and mental disorders
Panic Disorder
• Recurrent unexpected panic attacks and for a
one month period or more of:
– Persistent worry about having additional
attacks
– Worry about the implications of the attacks
– Significant change in behavior because of
the attacks
A Panic Attack is:
A discrete period of intense fear in which 4 of the following
Symptoms abruptly develop and peak within 10 minutes:
• Palpitations or rapid
heart rate
• Sweating
• Trembling or shaking
• Shortness of breath
• Feeling of choking
• Chest pain or
discomfort
• Nausea
• Chills or heat
sensations
• Paresthesias
• Feeling dizzy or faint
• Derealization or
depersonalization
• Fear of losing control
or going crazy
• Fear of dying
Panic disorder epidemiology
• 2-3% of general population; 5-10% of primary
care patients ---Onset in teens or early 20’s
• Female: male 2-3:1
Things to keep in mind
• A panic attack ≠ panic
disorder
• Panic disorder often
has a waxing and
waning course
Panic Disorder Comorbidity
• 50-60% have lifetime major depression
– One third have current depression
• 20-25% have history substance dependence
Agoraphobia
Agoraphobia
• Marked fear or anxiety for more than 6 months
about two or more of the following 5 situations:
– Using public transportation
– Being in open spaces
– Being in enclosed spaces
– Standing in line or being in a crowd
– Being outside of the home alone
Agoraphobia
• The individual fears or avoids these situations
because escape might be difficult or help might
not be available
• The agoraphobic situations almost always
provoke anxiety
• Anxiety is out of proportion to the actual threat
posed by the situation
• The agoraphobic situations are avoided or
endured with intense anxiety
• The avoidance, fear or anxiety significantly
interferes with their routine or function
Social Anxiety Disorder
Social Anxiety Disorder (SAD)
• Marked fear of one or more social or performance
situations in which the person is exposed to the possible
scrutiny of others and fears he will act in a way that will
be humiliating
• Exposure to the feared situation almost invariably
provokes anxiety
• Anxiety is out of proportion to the actual threat posed by
the situation
• The anxiety lasts more than 6 months
• The feared situation is avoided or endured with distress
• The avoidance, fear or distress significantly interferes
with their routine or function
SAD epidemiology
• 7% of general population
• Age of onset teens; more common in women.
Stein found half of SAD patients had onset of sx
by age 13 and 90% by age 23.
• Causes significant disability
• Increased depressive disorders
Incidence of social anxiety disorders and the consistent risk for secondary depression in the first
three decades of life. Arch Gen Psychiatry 2007 Mar(4):221-232
Social Anxiety Disorder treatment
• Social skills training, behavior therapy, cognitive
therapy
• Medication – SSRIs, SNRIs, MAOIs,
benzodiazepines, gabapentin
TREATMENT OF ANXIETY DISORDERS
• Promote active coping
• MEDICATION: Provide information, directly
moderate neurobiology
• COGNITIVE BEHAVIORAL TREATMENT:
Provide information, Change neural circuitry
through exposure, Teach specific coping
techniques
PATIENTS AND FAMILY NEED INFORMATION
• About the illness: symptoms and course
– Biological aspects of anxiety
– Psychological components of symptoms
• Simple principles of conditioned responses
• Role of thoughts and behaviors in affecting
emotions
• Relationship between physiology, psychology
and treatment
PHARMACOLOGIC TREATMENT OF
ANXIETY DISORDERS: EARLY GENERATION
• Typical Antidepressants, for example,
– imipramine,
– clomipramine,
– nortriptyline,
– monoamine oxidase Inhibitors (like phenelzine)
• Benzodiazepines (alprazolam, clonazepam)
• Most worked for some, but not all of the anxiety
disorders
PHARMACOLOGIC TREATMENT OF ANXIETY
DISORDERS: NEWER MEDICATIONS
SSRIs and SNRIs
• citalopram
• fluoxetine
• fluvoxamine
• paroxetine
• sertraline
• Escitalopram
• Venlafaxine
• Doluxetine
Act as “broad spectrum” antianxiety agents
COGNITIVE BEHAVIORAL TREATMENTS
ARE EQUALLY EFFICACIOUS AS
MEDICATION FOR ANXIETY DISORDERS
•Preferred by many patients
•Associated with improvement in
biological as well as psychological
abnormalities
CBT MODEL OF PANIC DISORDER
Bodily Sensation
Catastrophic
misinterpretation
Physiological
arousal
Conditioned
response
Fear
Behavioral Anxiety Management
• Decrease Physiological Arousal
– Slow Abdominal Breathing
– Progressive Muscle Relaxation
• Re-Instate Normal Activities
• Exposure to Anxiety Provoking Situations
Cognitive Therapy
• Target Negative Thinking and Logical Errors
– Overestimation of Probability of Negative
Consequences
– Catastrophizing
• Techniques
– Identify and Challenge Negative Thoughts
– Provide Alternative Explanations
WHAT TO REMEMBER ABOUT ANXIETY
DISORDERS
• Common and debilitating conditions
• Often co-occur with other medical and
psychiatric conditions
• Characterized by
– prominent somatic symptoms
– catastrophic misinterpretations
– escape and avoidance behaviors
WHAT TO REMEMBER ABOUT ANXIETY
DISORDERS
• Avoidance
– Can prevent help-seeking
– Inhibits reporting of symptoms
• Highly treatable
– Medication, especially serotonin active
antidepressants
– Cognitive behavioral treatment
Obsessive-Compulsive Disorders
•
•
•
•
•
obsessive-compulsive disorder,.
body dysmorphic disorder,
hoarding disorder,
Trichotillomania
excoriation disorder
OCD
• OBSESSIONS:
Recurrent and persistent thoughts
• COMPULSIONS:
Repetitive behaviors or mental acts
• Distress/Dysfunction
OCD
• Contamination concerns  hand-washing
• Possible harm concerns  checking
• Symmetry concerns  symmetry behaviours
Obsessive-Compulsive Disorder
• Diagnosis is called for when symptoms:
– Feel excessive or unreasonable
– Cause great distress
– Take up much time
– Interfere with daily functions
48
NOT OCD
• Obsessive-compulsive personality disorder
• Pathological or problem gambling, compulsive
sexual disorder, problematic internet use
• Hoarding concerns  hoarding behaviors
• Being a meticulous professional or student
OCD
• 4th most common psychiatric disorder in one USA
study
• 10th most disabling of all medical disorders in
WHO BoD study
• Subclinical washing, checking, symmetry,
symptoms are common
(Ruscio et al, 2008)
OCD Spectrum
• Range of disorders with intrusive thoughts and
repetitive behaviors
•
•
•
•
•
•
- Tourette’s syndrome
- Body Dysmorphic Disorder
- Hypochondriasis
- Hoarding Disorder
- Trichotillomania
- Skin Picking Disorder
Epidemiology
The lifetime prevalence of OCD is between 2 and
3%. Child/adolescent prevalence is 1-2.3%.
There is similar epidemiology among diverse
cultures (studies in Europe, Asia and Africa have
confirmed rates).
In adults, male and female prevalence is the
same. In children and adolescents, males are
more likely than females to be affected.
Epidemiology II
• Mean age of onset is approximately 20 years old
(males with mean around 19 and females
around 22).
• Two-thirds of affected people have onset before
age 25. Less than 15% have onset after age 35.
• OCD occurs less often among blacks than
whites in the US, but access to health care may
be a confounding variable.
OCD Etiology
Biological
Psychological
Social
Serotonin hypothesis
Psychodynamic
Accomodation
Brain Imaging
Personality
Adaptive mechanisms
Genetics
Behavioral
Neuroimmunologoy
Biological
Serotonin Hypothesis
Clomipramine, SSRI’s, mCPP
Neuroimmunology
PANDAS, autoimmune
Genetics
1st degree relatives 35%, Monozygotes 8087%
Neuroimaging
Orbital Frontal Cortex, Basal Ganglia, Anterior
Cingulate Gyrus
Screening Questions
• Why Screen?
– Lag time from onset to diagnosis, shame
• Do you have repetitive thoughts that make you
anxious and that you can’t get rid of no matter
how hard you try?
• Do you keep things extremely clean or wash
your hands frequently?
• Do you check things to excess?
• Check for comorbidity
– Lifetime MDD in adults is 2/3. OCD often
precedes MDD in kids and adults
Treatment
•
•
•
•
Pharmacotherapy
Cognitive-Behavioral Therapy
Psychosurgery
Deep Brain Stimulation
OCD:
Biological Perspective
Serotonin-based antidepressants (sertraline;
Paroxetine,clomipraine)
• Bring improvement to 50–80% of those with
OCD
• Relapse occurs if medication is stopped
Research suggests that combination therapy
(medication + cognitive behavioral therapy
approaches) may be most effective
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OCD:
Behavioral Perspective
 In fearful situation, perform a particular act
(washing hands)
 When threat lifts, associate improvement
with random act
 After repeated associations, believe
compulsion is changing situation
 Act becomes method to avoiding or
reducing anxiety
60
OCD:
Behavioral Perspective
• Behavioral therapy
– Exposure and response prevention (ERP)
• Clients are repeatedly exposed to anxietyprovoking stimuli and told to resist performing
compulsions
• Therapists often model behavior while client
watches
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Summary
• Anxiety disorders are common
• They are distressing and cause loss of function
• They occur commonly with other co-morbid
psychiatric disorders
• They are amenable to pharmacological and
psychological treatment
DON’T WORRY
BE HAPPY
BE HAPPY
BE HAPPY
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